Time to listen In NHS hospitals Dignity and nutrition inspection programme 2012 - March 2013

 
Time to listen In NHS hospitals Dignity and nutrition inspection programme 2012 - March 2013
Time to listen
          In NHS hospitals
          Dignity and nutrition inspection programme
          2012

                                                March 2013

9346-CQC-Time to listen-COVER.indd 1                    13/03/2013 20:47
Time to listen In NHS hospitals Dignity and nutrition inspection programme 2012 - March 2013
The Care Quality Commission is the independent regulator of health care
              and adult social care services in England. We also protect the interests of
              people whose rights are restricted under the Mental Health Act. Whether
              services are provided by the NHS, local authorities or by private or
              voluntary organisations, we focus on:
              ●●   Identifying risks to the quality and safety of people’s care.
              ●●   Acting swiftly to help eliminate poor quality care.
              ●●   Making sure care is centred on people’s needs and protects their rights.

9346-CQC-Time to listen-COVER.indd 2                                                          13/03/2013 20:47
Time to listen In NHS hospitals Dignity and nutrition inspection programme 2012 - March 2013
Contents

               Foreword                                                                                   3

               Summary                                                                                    5
               What worked well                                                                           5�
               What needs to improve                                                                      6�
               Conclusions and recommendations                                                            8�

               1. Introduction                                                                            9

               2. How we carried out these inspections                                                   10
               Advisory Group                                                                            10 �
               The sample                                                                                10 �
               The standards                                                                             11 �
               The inspections                                                                           11 �
               Our inspection teams                                                                      12 �
               Tools                                                                                     12 �

               3. Our findings                                                                           13
               Overall levels of hospitals meeting the standards                                         13 �
               Respecting and involving people who use services                                          14 �
               Meeting people’s nutritional needs                                                        16 �
               Safeguarding people who use services from abuse                                           19 �
               Staffing                                                                                  20 �
               Records                                                                                   22 �

               4. Follow up                                                                              24
               Publication and follow-up                                                                 24 �
               Evaluation                                                                                24 �
               Patient led assessments of the care environment                                           24 �

               5. Conclusions and recommendations                                                        25

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview    1
Appendix A: Tables of findings                                                 26
                              Regional comparisons                                                           26 �
                              Comparison by trust type                                                       26 �
                              Dementia                                                                       27 �
                              Comparisons with the first programme of dignity and nutrition inspections
                              for NHS hospitals                                                              28 �
                              Common questions                                                               29 �

                              Appendix B: Advisory Group                                                     31

                              Appendix C: How CQC checks whether national standards
                              are being met                                                                  32

2   Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Foreword

               With life expectancy increasing, and a growing population of older people in
               England, the spotlight has been turned on the quality of care they receive.

               CQC has already drawn attention to cultures of care that too often are ‘task-
               based’ when they should be person-centred, and where the unacceptable
               become the norm. Recently published reports from the Patients Association
               and our own State of Care report continue to highlight episodes of poor care.

               In October 2011, we published our first report on 100 unannounced inspections
               of NHS hospital acute trusts, where we looked in detail at standards of dignity
               and nutrition on wards caring for older people. While we were able to report
               examples of good care, we also found that 20 hospitals were failing to meet the
               national standards that people should expect.

               We have followed this up with two further inspection programmes looking at
               dignity and nutrition issues for older people. One was our first in-depth look
               at the experiences of older people in care homes. The other was a further
               programme of inspections in 50 NHS trusts, this time including both mental
               health and acute trusts.

               Overall, we found that most patients and residents were receiving the levels of
               care and support that they should expect. This report sets out what was working
               well and describes how this was being achieved – an approach that is supported
               by the emerging themes from our recent consultation on our strategy. We need
               to report on good care, so the public can be clearer about what it is they should
               be expecting. Taking the opportunity to share good practice with providers
               should also encourage them to improve.

               However, it is unacceptable that we are still finding people who are being treated
               and cared for in ways that fail to meet national standards, and we have reported
               what needs to improve. Many of these improvements are not complex or time-
               consuming to make, and could be addressed through changes to systems and
               processes, or through taking steps to make sure the right culture is created to
               support staff in providing care.

               CQC continues to hold individual care providers to account and take action
               where improvements are not made. In addition, our reports are written to
               support providers in identifying the factors that need to be in place to make
               sure they are treating people with dignity and respect and are meeting their
               nutritional needs.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview   3
These inspection programmes were once more a collaborative effort, working
                              with practising professionals and Experts by Experience (people with direct
                              experience of care services) as part of our inspection teams. The first NHS
                              hospital programme was supported by professional nurses. This time we
                              broadened the skills and knowledge base of our practising professionals to
                              include geriatricians and dietitians. Advisory groups of experts in the field
                              provided advice and challenge to us throughout the process.

                              We are publishing two separate reports, one for the NHS and one for care
                              homes. This report describes our findings from the inspections of NHS hospitals.
                              We intend that these national reports will help providers, commissioners and
                              other stakeholders to improve the care that they are responsible for and deliver
                              a culture of care that puts people first.

                              David Prior                               David Behan
                              Chair                                     Chief Executive

4   Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Summary

               This programme of themed inspections looked at the care provided to older
               patients at 50 NHS trust hospitals in England during 2012, focusing on dignity
               and nutrition. It followed a programme of inspections of 100 hospitals in the
               previous year looking at the same broad themes.

               Comparing the results of the 2011 dignity and nutrition review with these latest
               findings, we were pleased to see that broadly more hospitals were meeting
               people’s nutritional needs. In 44 out of 50 hospitals (88%), patients were given
               a choice of food and drink to meet their nutritional needs and given help to eat
               and drink when they needed it. The corresponding figure in 2011 was 83%.

               On the other hand, there were fewer hospitals where we saw that patients were
               always treated with dignity and their privacy and independence respected. Out
               of 50 hospitals, 41 (82%) were meeting the standards for respecting patients’
               privacy and dignity and involving them in decisions about their care. This
               compares with 88% of hospitals in the 2011 review. It is clearly unacceptable
               that this position, poor to begin with, has deteriorated further.

               Overall we inspected the 50 hospitals against five standards: respecting and
               involving people, meeting their nutritional needs, safeguarding them from
               abuse, staffing, and records. We found that 33 hospitals were meeting all five
               standards. At the other end of the scale, three hospitals were meeting just two
               of the five standards, one hospital was meeting only one and one was not
               meeting any.

               Of the nine hospitals we inspected in both 2011 and 2012, seven had either
               improved or were continuing to meet the standards. For the other two hospitals,
               we identified concerns in staffing levels in one and record keeping in another.

               What worked well
               It is particularly disappointing that patients continue to receive poor care in
               some hospitals when our inspectors found many examples of hospitals that were
               providing good and excellent care in relation to patients’ dignity and nutrition.
               This was confirmed by the positive comments we received from patients and
               their families.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview   5
All hospitals can and should learn from each other in terms of what works well.
                              The following are some of the things highlighted by our inspectors. They are
                              part of a culture of care that puts patients first:
                              ●●   Staff documented patients’ wishes and preferences, involving relatives where
                                   the patient did not have the capacity to give that information themselves.
                                   This information was updated and reviewed regularly.
                              ●●   Patients were asked how they wanted to be addressed.
                              ●●   Staff were familiar with patients’ needs, and so could often anticipate their
                                   care requirements.
                              ●●   Hospitals had some means of helping to make sure that patients’ privacy was
                                   respected when bedside curtains were closed – for example by using ‘do not
                                   enter’ signs.
                              ●●   Hospitals provided flexible catering, including offering choice in meals, their
                                   portion size, and when they could be ordered.

                              We also found that those hospitals providing good care had systems firmly in
                              place to record and monitor patients’ needs:
                              ●●   Staff reviewed and adapted patients’ care plans in line with their changing
                                   needs.
                              ●●   Hospitals completed nutritional risk assessments when patients were admitted
                                   and reviewed these on an ongoing basis. Appropriate referrals were made to
                                   other health care professionals (for example, dietitians).
                              ●●   Staff recorded patients’ food intake and fluid balance accurately.
                              ●●   Patients’ weights were recorded and monitored if needed.

                              What needs to improve
                              Where CQC’s inspectors did find problems, there were some common failings.
                              Many of these issues arise from cultures of care that put tasks before people.

                              Respecting and involving people who use services
                              Forty-one of the 50 hospitals were meeting this standard. Where we found
                              problems, they included:
                              ●●   Staff not involving patients enough in care planning, or recording their
                                   preferences and dislikes.
                              ●●   Staff discussing confidential patient information in a public area.
                              ●●   Patients not having anywhere to lock away their personal belongings.
                              ●●   Staff ‘talking over’ patients as though they were not there.
                              ●●   Patients not always being able to reach call bells, or staff not responding
                                   to them in a reasonable time.

6   Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Meeting nutritional needs
               Forty-four of the 50 hospitals were meeting this standard. Where we found
               problems, they included:
               ●●   Staff not giving patients the help they need to eat and drink, or accurately
                    recording what they eat and drink.
               ●●   Hospitals not always giving patients a suitable choice of menu.
               ●●   Delays in clinical referrals for nutrition or dietetic advice.
               ●●   Many patients not being given the opportunity to wash their hands before
                    or after eating their meals.

               Safeguarding people who use services from abuse
               Forty-seven of the 50 hospitals were meeting this standard. Where we found
               problems, they included:
               ●●   Not all staff were knowledgeable and trained in safeguarding.
               ●●   Hospitals not having a formal system in place to learn from incidents.
               ●●   Some staff not being fully aware of the Mental Capacity Act 2005, or when
                    Deprivation of Liberty Safeguards might apply.

               Staffing
               Forty-seven of the 50 hospitals were meeting this standard. Where we found
               problems, they included:
               ●●   Patients told our inspectors that they waited a long time before staff answered
                    call bells. We saw that this was the case in some of our visits.
               ●●   Both staff and patients told us that there were not enough staff on duty to
                    meet the needs of patients.
               ●●   In one hospital, staff not following the findings of patients’ nutritional
                    assessments.

               Records
               Thirty-four of the 50 hospitals were meeting this standard. Where we found
               problems, they included:
               ●●   Some hospitals not carrying out individual risk assessments.
               ●●   Staff failing to update nutritional assessments.
               ●●   Staff monitoring patients’ food and fluid balance inaccurately.
               ●●   Hospitals not integrating their records system sufficiently, with paper and
                    digital systems both being used.
               ●●   Staff not completing records (we saw, for example, incomplete do not attempt
                    resuscitation (DNAR) records).

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview   7
Conclusions and recommendations
                              Most of the hospitals we inspected were caring for people with dignity, treating
                              them with respect, and supporting them to make sure their nutritional needs
                              were met. Compared with our previous dignity and nutrition programme, more
                              hospitals were meeting people’s nutritional needs but fewer hospitals were
                              meeting the standard on dignity and respect.

                              To make the improvements needed, the hospitals concerned must:
                              ●●   Implement the best systems to ensure people’s nutritional needs are identified
                                   and met. These needs should be reviewed, and any risks addressed, including
                                   making timely referrals for nutritional advice or treatment.
                              ●●   Make sure that all staff understand safeguarding and their responsibilities
                                   in protecting patients from the risk of abuse. This should include an
                                   understanding of the Mental Capacity Act 2005 and the Deprivation
                                   of Liberty Safeguards.
                              ●●   Improve the standard of record keeping, with staff maintaining accurate,
                                   appropriate information to support patient care, for example ensuring that
                                   decisions not to resuscitate (DNAR) are accurately recorded in line with best
                                   practice.

                              Above all, those involved in planning, commissioning and delivering care should
                              learn from what works well and increase their focus on ensuring people are
                              treated with dignity and shown respect.

8   Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
1. Introduction

               In October 2011, we published our first report on 100 unannounced inspections
               of NHS trusts, where we specifically looked at standards of dignity and nutrition
               on NHS acute hospital wards caring for older people.1 While we found examples
               of good and excellent care, we also reported that 20 hospitals were failing to
               meet the standards that the law says people should expect.

               Between July and August 2012, we carried out a further review of dignity and
               nutrition standards for patients at 50 NHS hospitals. We inspected a combination
               of hospitals that raised concern during the original review and a new sample that
               included some NHS mental health trusts. The individual hospital reports from
               these inspections have already been published on our website. This national
               report summarises what we found.

               Our published inspection reports on all 50 hospitals contain details of any
               actions they needed to take where they were not meeting the standards of
               quality and safety. We are following-up with these hospitals to ensure that these
               actions have been completed.

               We have also carried out a programme of inspections looking at dignity and
               nutrition in 500 care homes for older people across England. We are publishing
               a national report on these inspections at the same time as this report.2

               1 � Care Quality Commission (CQC), Dignity and nutrition inspection programme: National
                   overview, October 2011.
               2 � CQC, Time to listen: In care homes – Dignity and nutrition inspection programme 2012:
                   National overview, March 2013.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview     9
2. How we carried out
                              these inspections

                              The themed inspections ran between July and August 2012, focusing on dignity
                              and nutrition for older patients in hospital. The programme ran alongside our
                              ongoing inspections of hospitals in England.

                              Advisory Group
                              The programme was supported by an Advisory Group that provided advice and
                              challenge throughout the inspection programme.

                              Membership of the Advisory Group can be found in appendix B.

                              The sample
                              We identified 50 NHS trust hospitals to be included in the programme from 223
                              trusts nationally. The sample was made up of hospitals from 37 acute trusts and
                              13 mental health trusts. For each of these trusts we inspected two service areas
                              or wards caring for older people. We had inspected nine of these trusts as part
                              of our previous dignity and nutrition programme, but this time we inspected
                              different services or wards.

                              The number chosen from each of CQC’s four regions (North, Central, London and
                              South) was based on the proportional representation of each region within the
                              national population. London has the smallest proportion of NHS trust hospitals
                              nationally, therefore had the smallest number of locations within the sample group.

                              Table 1 below summarises the final allocation of inspections.

                              Table 1
                                    Region            Mental           Trust followed         Other acute   Total
                                                    health trust      up from previous          trusts
                                                                         programme
                                North                      4                    3                    9       16
                                Central                    4                    4                    6       14
                                South                      3                    1                    8       12
                                London                     2                    1                    5       8
                                Total                     13                    9                   28       50

10 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
The standards
              Each inspection looked at five of the national standards of quality and safety
              that are related to the theme of dignity and nutrition. These included two key
              standards: respecting and involving people who use services and meeting
              nutritional needs. The other standards were about safeguarding, staffing and
              record-keeping. For each standard, we identified two or three key areas (sub-
              themes) that the inspection teams looked at during the inspections, and which
              were used to describe our findings in the inspection reports (see box A).

                 Box A: The standards and sub-themes reviewed in the dignity
                 and nutrition themed inspections
                 Respecting and involving people who use services
                 ●●   Are people’s privacy and dignity respected?
                 ●●   Are people involved in making choices and decisions about their care?
                 Meeting nutritional needs
                 ●●   Are people given a choice of suitable food and drink to meet their
                      nutritional needs?
                 ●●   Are people’s religious or cultural backgrounds respected?
                 ●●   Are people supported to eat and drink sufficient amounts to meet their
                      needs?
                 Safeguarding people who use services from abuse
                 ●●   Are steps taken to prevent abuse?
                 ●●   Do people know how to raise concerns?
                 ●●   Are the Deprivation of Liberty Safeguards used appropriately?
                 Staffing
                 ●●   Are there sufficient numbers of staff?
                 ●●   Do staff have the appropriate skills, knowledge and experience?
                 Records
                 ●●   Are accurate records of appropriate information kept?
                 ●●   Are records stored securely?

              The inspections
              Themed inspections are one of three types of inspections we carry out. The
              others are planned inspections, which are part of our ongoing programme, and
              responsive inspections when we respond to a problem or concern. All of our
              inspections are carried out under the Health and Social Care Act 2008 which
              describes the regulations a registered provider must meet. Information on how
              CQC carries out its inspections and the national standards of quality and safety
              that it inspects against is included in appendix C.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 11
As part of the planning for each inspection we reviewed all the information we
                              held about each hospital and contacted relevant stakeholders, including local
                              involvement networks.

                              Apart from one inspection, we carried out our visits on a single day, including
                              a number of visits during the weekend. On each visit we visited at least two
                              ward or unit areas, typically arriving at 9am and staying until 4pm, though at
                              some locations the visit was staggered to allow us to observe breakfast or the
                              evening meal.

                              Our inspection teams
                              The programme was a collaborative effort, working with 31 practising
                              professionals (including geriatricians, nurses and dietitians) and 35 Experts
                              by Experience (people with direct experience of care services). Each inspection
                              was led by a CQC compliance inspector and, in most cases, was supported by
                              a second CQC inspector.

                              Experts by Experience took an active part in the inspection and talked to
                              patients and relatives using the service. They also looked at the environment,
                              saw how staff and patients interacted and what the atmosphere felt like.

                              Tools
                              In the inspections, we used specifically developed observation, interview and
                              record-tracking tools to help assess the quality of care given to older people with
                              the focus on dignity and nutrition. We spent time on hospital wards and units
                              that cared for older people, observing a meal time, and talking to patients,
                              relatives and a variety of staff.

                              Many of the places we were inspecting were caring for, and treating, patients
                              with dementia – either in mental health trust hospitals and units or in acute
                              hospitals. Our inspectors used an observation tool, called the Short
                              Observational Framework for Inspection 2, which is specifically designed to
                              help capture the experiences of people who may not be able to express this
                              for themselves.

12 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
3. Our findings

              Overall levels of hospitals meeting the
              standards
              We inspected 50 hospitals against five standards overall: respecting and
              involving people, meeting their nutritional needs, safeguarding them from
              abuse, staffing, and records. We found that:
              ●●   33 hospitals were meeting all five standards. �
              ●●   5 were meeting four out of the five standards. �
              ●●   7 were meeting three out of the five standards. �
              ●●   3 were meeting just two of the five standards. �
              ●●   1 hospital was only meeting one of the five standards. �
              ●●   1 hospital was not meeting any of the five standards. �
              ●●   41 of the 50 hospitals were meeting the standard about respecting and
                   involving patients who use services.
              ●●   44 of the 50 hospitals were meeting the standard about meeting nutritional
                   needs.
              ●●   47 of the 50 hospitals were meeting the standard about safeguarding.
              ●●   47 of the 50 hospitals were meeting the standard about staffing.
              ●●   34 of the 50 hospitals were meeting the standard about records.

              Of the nine hospitals we inspected in both 2011 and 2012, seven had either
              improved or were continuing to meet the standards. For the other two hospitals,
              we identified concerns in staffing levels in one and record keeping in another.

              Overall, we found that mental health trusts performed slightly better than the
              acute trusts in all but one of the five standards inspected.

              You can find detailed figures comparing performance against the standards
              between, for example, trust types and regions in appendix A

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 13
Respecting and involving people who use
                              services
                              Forty-one of the 50 hospitals were meeting the standard about respecting and
                              involving patients who use services. For this inspection programme, we checked
                              this standard under two subheadings – ‘Are patients’ privacy and dignity
                              respected?’ and ‘Are patients involved in making decisions about their care
                              and treatment?’.

                              Are patients’ privacy and dignity respected?
                              What worked well
                              In the hospitals meeting the standard we saw the following examples, which
                              reflected care that respected patients’ privacy and dignity:
                              ●●   Ward staff were trained in dementia care and understood issues of mental
                                   capacity.
                              ●●   The hospital had some means of helping to make sure that patients’ privacy
                                   was respected when bedside curtains were closed – for example, ‘do not enter’
                                   signs, or staff carrying a clothes peg in their pocket to keep privacy curtains
                                   together.
                              ●●   Separate toilets and bathrooms for men and women.

                              Comments from patients at hospitals meeting this standard included, “It’s fine.
                              They go out of their way to be helpful. Staff showed me my call bell and they
                              are always available.”

                              What needs to improve
                              Of the nine hospitals not meeting the overall standard on respect and
                              involvement, eight were failing to respect people’s privacy and dignity. The key
                              themes we saw in hospitals not meeting this part of the standard were:

                              ●●   Staff making thoughtless comments that showed a lack of respect for the
                                   people in their care.
                              ●●   Staff discussing confidential patient information in a public area.
                              ●●   Patients not having anywhere to lock away their personal belongings.
                              ●●   Staff talking over patients as though they were not there.
                              ●●   Patients not always being able to reach call bells, or staff not responding
                                   to them in a reasonable time.

14 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Extracts from inspection reports
                   “For example, they [member of staff] stood directly behind a patient and
                   leant over them to cut up their food. They also called across to a colleague
                   who was supporting a patient with eating, ‘I think you’ve got a lost cause
                   there’, referring to the fact that the patient was falling asleep during the
                   meal.”
                   “We overheard staff speaking by telephone in the corridor at a nurse’s
                   station about patients’ needs.”
                   “We looked at care plans and found that the staff referred to the person as
                   ‘the patient’ and not by their name.”
                   “One person commented that a member of night staff had displayed
                   annoyance when they had drawn their attention to a patient who was
                   calling for assistance. They said that the member of night staff had told
                   them not to interfere. They told us that this had made them feel frightened
                   to call for help at night.”
                   “We noted that on Ward A many people did not have their nurse call bells
                   within reach. We observed that when patients did use their nurse call bells,
                   there was a 45 minute delay before the patient was attended which meant
                   that the patient was not able to drink their cup of tea while it was still hot.”
                   “Staff made efforts to maintain patients’ dignity by using gowns and
                   drawing the curtains when providing personal care. However, on both
                   wards we saw that some curtains did not always close and this did not
                   afford people full privacy.”
                   “We also noticed that some patients could not reach their drink; this meant
                   that some patients had to wait for long periods for a drink.”

              Are patients involved in making decisions about their
              care and treatment?
              What worked well
              In the hospitals meeting this standard we saw the following examples of patients
              being involved in their care and treatment:
              ●●   Patients were asked how they wished to be addressed.
              ●●   Patients’ wishes and preferences were documented, involving relatives where
                   the patient did not have the capacity to convey that information themselves.
                   This information was updated and reviewed regularly.
              ●●   Care plans were reviewed and adapted in line with patients’ changing needs.

              Comments from patients at hospitals meeting this standard included, “The
              doctor has been today and has explained everything to me.”

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 15
What needs to improve
                              Of the nine hospitals not meeting the overall standard on respect and
                              involvement, six were failing to involve people in choices and decisions about
                              their care and not documenting their preferences or dislikes.

                                   Extracts from inspection reports
                                   “Staff we spoke with were not aware of patients’ individual religious needs.
                                   We spoke with one patient who told us that despite their strong beliefs and
                                   visits from their vicar on previous stays in the hospital, on this occasion no
                                   one had asked them about their faith and they were unaware of the
                                   services available at the hospital.”
                                   “We did not see many people being given the opportunity to be actively
                                   engaged in their care although staff that we spoke with told us they did
                                   seek the views and preferences of people they cared for. Staff said when
                                   a person was unable to communicate their needs they checked what was
                                   recorded in their care plan or referred to the person’s family or carers.
                                   We found that this did not always happen in practice.”

                              Meeting people’s nutritional needs
                              Forty-four of the 50 hospitals were meeting the standard about respecting and
                              involving patients who use services. For this inspection programme, we checked
                              this standard under three subheadings – ‘Are patients given a choice of suitable
                              food and drink to meet their nutritional needs?’, ‘Are patients’ religious and
                              cultural backgrounds respected?’, and ‘Are patients supported to eat and drink
                              sufficient amounts to meet their needs?’.

                              Are patients given a choice of suitable food and drink
                              to meet their nutritional needs?
                              What worked well
                              In the hospitals meeting this standard we saw the following examples of the
                              choice that patients had in what they ate and drank:
                              ●●   Menus offered a choice of suitable meals to meet all patients’ needs, including
                                   control over portion size and promotion of healthy eating options.
                              ●●   Patients were able to order food and drink throughout the day.
                              ●●   The hospital provided food and drink (such as snack boxes) for patients who
                                   had to miss a meal to attend an appointment.
                              ●●   In some dementia care units, meal options were plated up and shown to the
                                   patients to help them make their choices.

                              Comments from patients at hospitals meeting this standard included, “Food
                              choice is tremendous. At other hospitals I’ve been in, they ask you what you
                              want the day before. But here they ask you what you’d like for tea just before
                              you eat. It’s much better as you can just choose what you fancy.”

16 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
What needs to improve
              Of the six hospitals not meeting the overall standard on meeting nutritional
              needs, two were failing to give patients a choice of suitable food and drink, in
              the ways shown in the report extracts below.

                   Extracts from inspection reports
                   “One patient told us they had pureed food and felt that the portions were
                   too big as they were unable to eat more than a few spoonfuls. They said
                   that staff, ‘Can’t understand I can’t take it, they keep bringing it’. We
                   observed at lunchtime that this patient was served a large portion and
                   refused their meal after trying a small amount. We saw that the patient was
                   quite frustrated by being given portions they could not eat.”
                   “They [patient] were then offered a cheese sandwich. However, they were
                   given chips with salad and a chunk of cheese which they did not eat. Staff
                   did not give them a reason why they could not have the sandwich they had
                   chosen and no further main meal choices were offered when they did not
                   eat their meal.”

              Are patients’ religious and cultural backgrounds
              respected?
              What worked well
              In the hospitals we inspected it was generally commonplace for the menu to be
              varied and include options for patients who required a choice of diet in
              accordance with their religious or cultural needs.

              What needs to improve
              We found only one hospital that failed to meet this part of the standard, with
              the inspector reporting, “As information on patients’ religious and cultural needs
              were not recorded, those patients who were unable to make their preferences
              known may not have received food and drink that met their individual needs.”

              Are patients supported to eat and drink sufficient
              amounts to meet their needs?
              What worked well
              In the hospitals meeting this standard we saw the following examples of patients
              being supported:
              ●●   Protected mealtimes, so that patients were not interrupted.
              ●●   Systems for identifying patients with particular nutritional needs – for
                   example, using red trays to identify patients who need additional help to eat
                   and drink.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 17
●●   Nutritional risk assessments completed on admission and reviewed on an
                                   ongoing basis.
                              ●●   Referrals made to dietitians and speech and language therapists.
                              ●●   Where appropriate, the completion of accurate food intake and fluid balance
                                   records.
                              ●●   Enough staff on duty to ensure that all patients received the support they
                                   needed to eat and drink.

                              Comments from patients meeting this standard included, “They are very
                              concerned here about you drinking enough.”

                              What needs to improve
                              Of the six hospitals not meeting the overall standard on meeting nutritional
                              needs, five were failing to provide adequate support for patients to eat and drink
                              sufficient amounts for their needs. All but one hospital was using a nutritional
                              risk assessment tool to identify those patients at risk of malnutrition. However,
                              the fact that 10% of hospitals were failing to meet this aspect of the standard is
                              chiefly explained by staff not properly using these tools, or generally not being
                              aware of the basic support needs of patients. This is reflected in the extracts
                              below.

                                   Extracts from inspection reports
                                   “Another person who was in need of some support to eat was given some
                                   assistance by staff to start her meal. This support was abandoned after a
                                   couple of minutes and her ability to help herself quickly deteriorated as she
                                   tried to use a knife as a spoon with little effect.”
                                   “We saw that some patients did not receive appropriate support and
                                   encouragement. For example, staff woke one patient when they took the
                                   patient’s lunch to them. The patient went back to sleep and the meal
                                   remained in front of them until they woke up.”
                                   “On the stroke ward staff concentrated on delivering the food in a timely
                                   manner, but patients were not always positioned in a way that helped them
                                   to eat without assistance. For example food was left for a patient who was
                                   lying in bed by the bedside table. The person was slumped in bed and the
                                   table was not near the person. They had to call for assistance. We observed
                                   a care assistant remove a tray without asking if the patient had finished.”
                                   “The food charts were not always completed for evening meals and had not
                                   been reviewed to ensure that people’s nutritional needs were regularly
                                   updated. This meant that there was insufficient evidence to inform clinical
                                   decisions about treatments and interventions in order to ensure people
                                   were protected from inadequate nutrition and hydration.”
                                   “Two patient records we looked at had identified clinical nutritional
                                   interventions. However, in one instance the procedure had not been
                                   completed. The patient had not received a Malnutrition Universal Screening
                                   Tool assessment and therefore had not been referred for a dietetic review.”

18 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Safeguarding people who use services
              from abuse
              For these inspections, we checked what steps are taken to prevent abuse,
              whether people know how to raise concerns, and whether staff use the
              Deprivation of Liberty Safeguards appropriately.

              What worked well
              Forty-seven of the 50 hospitals were meeting the standard about safeguarding.
              Here, we saw the following examples, which reflected that patients were
              safeguarded from the risk of abuse:
              ●●   Staff had received training in the trust’s safeguarding policies and procedures.
                   They were confident in being able to recognise the potential types of abuse
                   and were able to describe how they would report them.
              ●●   The trust had a safeguarding lead in post.
              ●●   Patients and their relatives knew how to raise a concern about their care.
              ●●   The trust had a whistleblowing policy and procedure and staff could show use
                   how they would use it.
              ●●   Staff understood mental capacity.

              What needs to improve
              In the three hospitals that were not meeting the standard about safeguarding,
              the key themes we saw were:
              ●●   Not all staff knew about or had received training in safeguarding.
              ●●   There was no formal system in place to learn from incidents.
              ●●   Some staff were not fully aware of the Mental Capacity Act 2005 or when
                   Deprivation of Liberty Safeguards might apply.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 19
Extracts from inspection reports
                                   “The staff we spoke with did not recognise that meeting people’s needs
                                   could reduce the potential for abuse. We found evidence that not all
                                   patients had received appropriate assessments of physical and mental
                                   needs. This omission means that patients were not always safeguarded from
                                   the risk of abuse.”
                                   “Staff did not demonstrate an understanding of the need to report
                                   safeguarding incidents to the local authority safeguarding team, although
                                   the safeguarding policy for the trust did direct staff to do this.”
                                   “We asked the ward sisters what the staff had learnt from these incidents;
                                   they told us the information about incidents were not available to staff.
                                   There was no evidence that there had been learning from these incidents.”
                                   “We spoke with staff who were uncertain when capacity assessments would
                                   be necessary or how a person’s liberty may be deprived.”
                                   “Staff were not sure who was responsible for establishing whether a patient
                                   had mental capacity.”

                              Staffing
                              For these inspections, we checked whether hospitals had sufficient numbers of
                              staff, and if staff had the appropriate skills, knowledge and experience.

                              What worked well
                              Forty-seven out of 50 hospitals were meeting the standard about staffing. Here,
                              we saw the following examples, which reflected that there were sufficient
                              numbers of suitable skilled and experienced staff on duty.
                              ●●   People were being helped or cared for when they needed it. �
                              ●●   Staff were answering call bells promptly. �
                              ●●   Hospitals had access to additional staff when required, often through banks or
                                   agencies.
                              ●●   Staffing numbers were linked to the needs and dependencies of the patients.
                              ●●   Staff were familiar with patients’ needs, and so could often anticipate their
                                   care requirements.
                              ●●   Staff had carried out training specifically related to nutrition.

                              Comments from patients at hospitals meeting this standard included, “Although
                              the unit is very busy, staff have always got time to talk and they seem to work as
                              a team.”

20 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
What needs to improve
              In the three hospitals that did not meet the standard on staffing, the key themes
              were:
              ●●   Patients saying that it took a long time to have their call bells answered. We
                   also saw this during our visits.
              ●●   Both staff and patients told us that there was just not enough staff on duty to
                   meet the needs of patients. This was often a problem because the hospitals
                   could not replace staff who were absent due to staff sickness or other short-
                   notice absence.
              ●●   Only one hospital was failing to ensure staff had the appropriate skills,
                   knowledge and experience, and this was because staff did not have the right
                   skills to use a nutritional screening tool properly and were not trained to
                   manage patients with dementia.

                   Extracts from inspection reports
                   “Patients on both wards told us that staff took a long time to respond to
                   call bells. Patients said that this caused them embarrassment and
                   inconvenience as they had to wait long periods to be supported to go to
                   the toilet or eat their meals.”
                   “We saw patients waiting for long periods to be sat up to have a drink.
                   One nurse explained that due to the high dependency levels on the ward
                   they were not able to get round to everyone, although they did say that
                   they would be able to respond if there was an emergency.”
                   “All staff told us they considered that staffing levels were inadequate to
                   meet the needs of patients on the ward.”
                   “We spoke with staff who said they had received training from the dietitian
                   on how to complete the nutritional assessment tool. However, the nursing
                   staff were not completing or following the instructions on the nutritional
                   screening and assessment tool. This meant that people were not being
                   identified as being at risk of poor nutrition or hydration.”
                   “We observed that staff were busy and did not notice that the call bells and
                   drinks were not within reach or that some patients were uncomfortable.
                   The staff we spoke with told us they were very busy and had not been
                   trained in looking after patients with dementia.”

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 21
Records
                              For these inspections, we checked whether hospitals kept accurate records
                              of appropriate information, and whether these records were stored securely.

                              What worked well
                              Thirty-four of the 50 hospitals were meeting the standard about records. Here,
                              we saw the following examples, which reflected that records were both accurate
                              and fit for purpose, and were securely and confidentially stored.
                              ●●   Multi-disciplinary records showed that patients had their nutritional risk
                                   assessed on admission and then this was regularly reviewed. Appropriate
                                   referrals were made to other healthcare professionals (for example, dietitians).
                              ●●   Patients’ weights were recorded and monitored if needed.
                              ●●   Records of patients’ food intake and fluid balance were accurately completed.
                              ●●   Working records, such as fluid balance charts, were kept near to the patient,
                                   with medical notes holding confidential information being held securely but
                                   within easy reach of staff.

                              What needs to improve
                              Sixteen hospitals were not meeting the standard on records, although we judged
                              14 of these as having a minor impact on patients’ health, safety and welfare.
                              The key themes we saw in these hospitals were:
                              ●●   A lack of proper individualised risk assessments. �
                              ●●   Staff failing to update nutritional assessments. �
                              ●●   Inaccurate food and fluid balance monitoring. �
                              ●●   Staff using both paper and IT-based record systems. �
                              ●●   Staff failing to complete records. This was especially the case with ’do not
                                   attempt resuscitation’ records.
                              ●●   Only one hospital was failing to keep records secure, since patient information
                                   was not stored confidentially.

22 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Extracts from inspection reports
                 “We reviewed the healthcare records of five patients on the ward. We
                 found in four records that the patient’s fluid intake and output was not
                 consistently recorded. For example, for one patient whose fluid intake and
                 output were being monitored, we saw that over a period of six days the
                 fluid balance chart had been completed on three days. Another patient’s
                 records showed that fluid balance charts had been completed in detail on
                 two days out of five. On two days the charts had been partially completed
                 and on one day the chart had been left blank.”
                 “In another record we saw there was no documented evidence of why a
                 patient remained nil by mouth for nine days and there was no audit trail
                 to record the clinical decision process.”
                 “We reviewed ‘do not attempt resuscitation’ (DNAR) forms that we found
                 in the healthcare records of 12 patients on the ward. We noted that four
                 DNAR forms had been completed in full and this included a record of
                 discussions with the patient or their relative about the decision. However,
                 the other eight DNAR forms were incomplete. The eight forms either failed
                 to record whether or not the patient had the ‘capacity’ to make the
                 decision themselves or, where they did not have capacity, there was no
                 record that a relative had been contacted or spoken with. This meant that
                 two thirds of the forms did not record the necessary information in relation
                 to the decision not to attempt resuscitation.”
                 “We observed that confidential and sensitive information was kept with
                 patients’ names on a white board, which could be seen by members of the
                 public. For example, we were able to ascertain which patients required
                 assessments, including those for mental capacity, and which patients were
                 catheterised.”

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 23
4. Follow up

                              Publication and follow up
                              We have published reports for each of the 50 hospitals inspected as part of this
                              programme. They are available at: www.cqc.org.uk/DANI

                              Where a hospital was not meeting a standard, we judged what impact this was
                              having on people using the service, and then asked the trust to send us a report
                              setting out what they intend to do. When they have made the required
                              improvements we check that the provider is meeting the standard. This will often
                              involve a follow-up inspection, but can be done by reviewing information from
                              the trust. If, on follow-up the standard is met, we update our website. If it’s not,
                              we consider our next actions using our enforcement policy as a guide.

                              Evaluation
                              We are currently evaluating our regulatory activity and will publish the findings
                              later this year. This includes all of our different inspection methodologies and
                              includes themed inspections. This work will help us identify the impact of our
                              work and the best use of our resources.

                              Patient-Led Assessments of the Care
                              Environment (PLACE)
                              On 6 January 2012, the Prime Minister announced that a new patient-led
                              inspection regime would be introduced covering privacy and dignity, food and
                              cleanliness in hospitals. The results of these inspections (which will replace the
                              current Patient Environment Action Team (PEAT) inspections from April 2013)
                              will be reported on publicly, to help drive up standards of care. The key feature
                              will be the involvement of patients, or their representatives, at all stages,
                              including development of the system, the inspection process and validation
                              of inspections.

                              Following discussions with a number of organisations and consultations with
                              patient representative organisations a proposed process and assessment –
                              PLACE (Patient-Led Assessment of Care Environments) – has been developed by
                              The Information Centre for health and social care. It is envisaged that the PLACE
                              inspection programme will begin soon after April 2013. We will make sure that
                              the findings from these inspections inform our assessments of risk and
                              inspection programmes.

24 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
5. Conclusions and
              recommendations

              Most of the hospitals we inspected were caring for people with dignity, treating
              them with respect, and supporting them to make sure their nutritional needs
              were met. Compared with our previous dignity and nutrition programme, more
              hospitals were meeting people’s nutritional needs but fewer hospitals were
              meeting the standard on dignity and respect.

              To make the improvements needed, the hospitals concerned must:
              ●●   Implement the best systems to ensure people’s nutritional needs are identified
                   and met. These needs should be reviewed, and any risks addressed, including
                   making timely referrals for nutritional advice or treatment.
              ●●   Make sure that all staff understand safeguarding and their responsibilities in
                   protecting patients from the risk of abuse. This should include an
                   understanding of the Mental Capacity Act 2005 and the Deprivation of
                   Liberty Safeguards.
              ●●   Improve the standard of record keeping, with staff maintaining accurate,
                   appropriate information to support patient care, for example ensuring that
                   decisions not to resuscitate (DNAR) are accurately recorded in line with best
                   practice.

              Above all, those involved in planning, commissioning and delivering care should
              learn from what works well and increase their focus on ensuring people are
              treated with dignity and shown respect.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 25
Appendix A:
                              Tables of findings

                              Regional comparisons
                              Table 2 gives the breakdown of hospitals meeting the national standards by CQC
                              region. All figures in the following tables are in proportion to the number of
                              hospital locations in each region.

                              The North region had the highest level meeting three standards (nutritional
                              needs, safeguarding and staffing), but the lowest level in meeting the standard
                              relating to records.

                              Table 2: Performance by region (% meeting the standards)
                                                                      Region, number of hospitals inspected,
                                                                          and % meeting the standards
                                                                        16            12            8         14
                                Standard                              North         South       London      Central
                                Respecting and involving              81.3%         83.3%        87.5%      78.6%
                                people who use services
                                Meeting nutritional needs             93.8%         91.7%        87.5%      78.6%
                                Safeguarding people who use           100%          100%          75%       92.9%
                                services from abuse
                                Staffing                              100%          100%         87.5%      85.7%
                                Records                               62.5%         83.3%         75%       64.3%

                              Comparison by trust type
                              Our sample of 50 trusts included 37 acute hospitals and 13 mental health
                              hospitals. Table 3 shows the difference in levels of performance against the five
                              inspected standards between acute and mental health trusts.

                              Acute trusts only outperformed mental health trusts in the standard concerning
                              safeguarding. Performance was higher in mental health trusts for the other four
                              standards inspected.

26 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Table 3: Performance by trust type (% meeting the standards)
                            Standard                  Acute trusts (37)           Mental health
                                                                                   trusts (13)
                Respecting and involving                     81.1%                      84.6%
                people who use services
                Meeting nutritional needs                    86.5%                      92.3%
                Safeguarding people who use                  94.6%                      92.3%
                services from abuse
                Staffing                                     91.9%                      100%
                Records                                      67.6%                      76.9%

              Dementia
              Table 4 shows the levels of standards being met between hospital locations
              (wards/units) which either care for patients with dementia or do not and those
              who have a dedicated dementia unit or do not. The percentages in the table below
              are in proportion to the number of wards/units with or without dementia care.

              ●●   Locations that did not care for patients with dementia were more likely to
                   meet all five standards than those which do care for patients with dementia.
                   However, this is based on a relatively small number of locations which do not
                   care for patients with dementia – only seven.
              ●●   Locations that did not have a dedicated dementia care ward or unit were more
                   likely to meet the standard that relates to respecting and involving patients
                   (84.8% to 76.5%) than those that did have a dedicated ward/unit.
              ●●   Locations that did not have a dedicated dementia care ward/unit were less
                   likely to meet the standards relating to staffing and records than those which
                   did have a dedicated dementia unit/ward.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 27
Table 4: Performance by ward/unit type (% meeting the
                              standards)
                                                                           Number of locations
                                                          43                  7                 17                23
                                   Standard            Wards/            Wards/            There IS a         There IS
                                                     units that         units that         dedicated           NOT a
                                                     DO care for         DO NOT            dementia          dedicated
                                                      patients           care for          care unit/        dementia
                                                        with             patients             ward           care unit/
                                                      dementia             with                                 ward
                                                                        dementia
                                Respecting and          81.4%              85.7%             76.5%              84.8%
                                involving
                                people who use
                                services
                                Meeting                 86.0%              100%              88.2%              87.9%
                                nutritional
                                needs
                                Safeguarding            93.0%              100%              94.1%              93.9%
                                people who use
                                services from
                                abuse
                                Staffing                93.0%              100%               100%              90.9%
                                Records                 65.1%              85.7%             70.6%              66.7%

                              Comparisons with the first programme of
                              dignity and nutrition inspections for NHS
                              hospitals
                              The following table shows the difference in performance between hospitals
                              inspected as part of the first dignity and nutrition themed review (in 2011) and
                              those inspected for the second one (in 2012). In the first programme, only the
                              standards relating to respecting and involving patients and meeting nutritional
                              needs were inspected, and therefore only these standards and their constituent
                              sub-themes have been compared.3

                              3 � When drawing direct comparisons between the first and second programmes, it should also be
                                  noted that some issues not directly related to the standards being inspected were used in
                                  making judgements. For example, for the first programme, when we reported on the standard
                                  dealing with meeting nutritional needs, we included information where notes did not
                                  accurately record patients’ consumption of food and drink. In the second, we have broadened
                                  the scope of the standards we have looked at. So our inspectors checked issues about the
                                  accuracy of recording appropriate information when judging whether hospitals were meeting
                                  the standard about records.

28 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Locations inspected in 2012 tended to perform worse against the standard
              concerning privacy and dignity than the 100 locations inspected during the first
              programme. On the other hand, hospitals inspected in the 2011 programme had
              lower levels of performance for the standard relating to meeting nutritional
              needs than those inspected as part of the 2012 programme. It should be noted
              that no mental health trusts were inspected as part of the first programme.

              Table 5: Performance between the themed inspections in 2011
              and 2012
                                                            Number of hospital locations
                                                           100               50               37
                 Standard (and sub-theme)                Results          Results           Results
                                                       from 2011        from 2012         from 2012
                                                                         all trusts         – acute
                                                                                             trusts
                Respecting and involving                  88%               82%             81.1%
                people who use services
                 Privacy and dignity respected?           91%               84%             83.8%
                 Involved in making choices               85%               88%             86.5%
                 and decisions about their
                 care?
                Meeting nutritional needs                 83%               88%             86.5%
                 Choice of suitable food and              77%               96%             97.3%
                 drink to meet individual needs
                 Respect of religious or cultural         82%               98%             97.3%
                 backgrounds
                 Supported to meet eating and             89%               90%             86.5%
                 drinking needs

              Common questions
              As part of the programme, our inspection teams asked hospital staff four
              questions on each visit. The following table shows the responses to those
              common questions.

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 29
Table 6: Answers to our common questions in 2012
                                                                                                  Answers at the
                                                                                                   50 hospitals
                                                  Common questions                                 Yes      No
                                1. For every patient that you have pathway tracked                78%       22%
                                were choices and decisions about their care
                                documented?
                                2. Was there a record of patients’ individual food and            78%       22%
                                drink preferences?
                                3. Were any Deprivation of Liberty Safeguard                      30%       70%
                                authorisations in place for patients in the hospital?
                                4. Did the trust use a formal tool (eg, Malnutrition              98%       2%
                                Universal Screening Tool or MUST) to identify patients
                                who were at risk of malnutrition

                              1.    For every patient that you have pathway tracked were choices and
                                    decisions about their care documented?
                              At locations where choices and decisions about care were documented (for
                              everyone pathway tracked – ie, 39 locations), 92% were meeting the standard
                              about respecting and involving patients. However, at locations where choices and
                              decisions were not documented, more than half were not meeting the standard.

                              2.    Was there a record of patient’s individual food and drink
                                    preferences?
                              At locations where there was a record of patients’ individual food and drink
                              preferences (39 locations), 95% were meeting the standard about meeting
                              nutritional needs. However at locations where there was no such record, only
                              64% were meeting the standard.

                              3.    Were any Deprivation of Liberty Safeguard (DoLS) authorisations in
                                    place for patients in the hospital?
                              At locations where any DoLS authorisations were in place (15 locations), 93% of
                              the hospital locations inspected were meeting all the standards. But at locations
                              where there were no DoLS authorisations in place, only 54% were meeting all
                              the five standards inspected.

                              4.    Did the trust use a formal tool (eg, Malnutrition Universal Screening
                                    Tool or MUST) to identify patients who were at risk of malnutrition

                              All but one location used a nutritional risk assessment tool (such as MUST), so
                              comparisons between those that do and don’t use it are not really meaningful.
                              This question just asked whether the trust used a nutritional risk assessment.
                              This risk assessment was usually carried out on admission to the ward or unit.
                              The 98% compliance rate with this question did not relate to the number of
                              trusts that continued to review the nutritional risk on an ongoing basis.

30 Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview
Appendix B: Advisory
              Group

              This themed inspection programme had the support of an Advisory Group to:
              ●●   Provide expertise and experience to inform the approach and scope of the
                   programme.
              ●●   Comment and advise on the nature of the inspections in terms of focus (what
                   should we be looking at) and desired outcomes.
              ●●   Advise on the presentation of results from the inspection programme.
              ●●   Consider what actions need to be taken by the wider system, and what the
                   role of group members is in taking these forward.

              CQC is grateful for the time, support, advice and expertise given by the group.

              The group has no decision making authority regarding CQC’s regulatory activity.

              As well as members of CQC staff, the group comprised: �
              ●●   Daniel Blake, POhWER (independent advocacy agency) �
              ●●   Frances Blunden, NHS Confederation �
              ●●   Ailsa Brotherton, BAPEN (British Association for Parenteral and Enteral
                   Nutrition)
              ●●   Elaine Cass, Social Care Institute for Excellence
              ●●   Gary Fitzgerald, Action on Elder Abuse
              ●●   Clare Gorman, NHS Confederation
              ●●   Margot Gosney, Royal College of Physicians
              ●●   Anita Higham, Local involvement network representatives
              ●●   Elaine Jennings, British Dietetic Association
              ●●   Nicola Matthews, Kissing It Better
              ●●   Christine McKenzie, Royal College of Nursing
              ●●   Mary Milne, Age UK
              ●●   Kieran Mullen, Patients Association
              ●●   Jennifer Oates, Nursing and Midwifery Counci
              ●●   Gerry Zarb, Equality and Human Rights Commission

Time to listen – In NHS hospitals: Dignity and nutrition inspection programme 2012 – National overview 31
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